Making Sense

How do experienced clinicians see beyond the superficial and understand the trouble brewing behind the scenes, seemingly before there is any warning? Where does such an unearthly prescience of what is about to happen come from? How is it that one sees what another doesn’t?

Being an expert clinician is not just a matter of making the right decisions, it is a matter of knowing when there is a decision to be made. This process is called ‘sense-making’.

Sense-making is a meaning making process in which people faced with ambiguity or uncertainty “organize to make sense of equivocal inputs and enact this sense back into the world to make that world more orderly”.

Sense-making is about asking and answering the following two questions: “What is the story here?” and “Now, what do I do?”

Although sense-making and decision-making are often lumped together sense-making precedes decision-making. When action is the central focus, interpretation not choice is the core phenomenon.- from Croskerry P, et al. (2009)

When I trained as a doctor I was taught to view diagnostic and management decisions as a choice between a series of alternatives. But the ‘sense-making’ step was largely ignored – in reality, before such a ‘choice’ can be made, we must realise that such a choice needs to be made. Achieving this is particularly challenging in the chaotic environment of the emergency department, where patient encounters may be so confusing that we are not even sure why they have presented, and both time and information are scarce resources.

So, how can we create order on the edge of this chaos?

When we make sense of a clinical situation we are noticing cues or changes in a patients condition. We take this information and interpret it to create a plausible story (or stories) and then we act — and the results of our actions serve as a test of the plausibility of the story. The better we are at sense-making the more subtle the cues and changes that we notice, the more plausible the stories that we create, the faster we act, and the more closely we monitor the results. The difference between the novice and expert sense-maker is perhaps exemplified best in anaesthestics, where experienced anaesthestists are quicker to detect changes in the patient’s physiological status, and quicker to act.

Noticing the cues is perhaps the most important step, and it is usually simply a matter of being surprised. This occurs when something unexpected happens. This implies that we had expectations of what was going to happen in the first place!

There are some powerful barriers that prevent us from noticing these cues.

We all share the universal human tendency to fall victim to confirmation bias, that is we tend to selectively remember and believe that which reinforces what we already believe to be true. Don’t believe me? Well, maybe you have succumbed to the blind-spot bias — the universal cognitive disposition of believing that you are less subject to cognitive biases than your fellow human beings! Another barrier is that we deal with conditions that constantly evolve. Premature closure, making a diagnosis that is not yet ripe to made, can shut down our monitoring system and lead to erroneous decision making. Finally, to create plausible stories for the complex undifferentiated patient requires intense mental effort, which is difficult to sustain amid the constant interruptions and time pressures of the emergency department.

So, how can we become better at sense-making?

Surely it is not just a matter of becoming old and wise. How can we become wise, but young?

Here are some strategies to help you make sense:

Deal with problems not diagnoses Recognise that conditions constantly evolve in emergency situations and that we are prone to premature closure and confirmation bias. Diagnoses are always much easier in hindsight.

Learn to make explicit expectations so that violations are easier to spot. Predict what should be found on examination and on investigations if the working diagnosis is correct, and force yourself to re-examine your interpretation if these findings are absent.

Develop the habit of stepping back to assess what is happening. Periodically review cases and search for information that doesn’t fit.

Learn about situation awareness, how to become attuned to your environment and how to detect and correct errors.

Beware of ‘labels’ Labels are useful for interpreting cues but if too specific may lead to to entrapment bias. The importance of diagnosis is over-rated – undifferentiated RLQ pain is often a more useful label to work with than probable appendicitis or probable ovarian torsion. Keep labels broad, at least early in the diagnostic process.

Appoint a Devil’s Advocate This is often the role of the attending/ ED consultant, but if you’re alone it will have to be you! The Devil’s Advocate should ask questions like: “What else could be going on? Why do you think that? Have you considered this? What if this happened?”

Seek a variety of interpretations How does the physiotherapist, pharmacist, or nurse view what is happening? Different viewpoints give you more information to work with and help guard against confirmation bias.

Hopefully by becoming better sense-makers we can find that uneasy, but essential, balance between being able to commit to a decision and take action, yet still remaining open to change and avoiding entrapment.

Brilliant. Another reason that we call it evidence based medicine, it was built on the scientific method where ruling things out is as important (if not more so) because we can never definitively rule something in.

This site always inspires me to want to do a medical degree after a PhD. We shouldn’t maintain a wall between research and clinical. Each case sounds like a new research project where the experiments we run are vital to the body of knowledge we call a case history, leading to treatment. Further, nothing informs you of what challenges are greatest and in most need of being addressed like being in “the field”.

Thanks Luke It is a tricky one -- depends if you believe in Occam’s razor or Hickum’s dictum -- “the patient can have as many diseases as he or she likes” In reality it is often made more complicated when the tests we do are not 100% specific or sensitive I think a confirmatory test for one disease does make another less likely -- this is after all factored into the Well’s score for PE… If PE is not the number one diagnosis or equally likely at the outset, you miss out on a whopping 3 points The problem is figuring out how much less likely condition Y will be if condition X is ‘confirmed’ by a test… This will vary according to the individual patient, presentation, and conditions of interest (e.g. one may cause the other, or both diseases may have a common underlying etiology or predisposition) To avoid having to test further the pre-test probability will have to fall to less than the test ‘threshold’ for condition Y -- how low that threshold is depends on how certain you have to be in order to rule out Condition Y. This point of equipoise is determined by the morbidity and mortality of condition Y on one hand, but also the morbidity and mortality, and the cost, of further testing and treatment (e.g. the test could be a false positive, leading to a lifetime of unnecessary drug treatment, etc etc). As for cognitive biases, in most situations I think most of us tend to ‘search satisfice’ (“a bird in hand is worth two in the bush”) and pull out Occam’s Razor. In certain situations this may make us miss condition Y due to premature closure (http://lifeinthefastlane.com/to-err-is-human-002/). To guard against this, we use ‘rule out worst case scenario’ as a common mantra in emergency medicine. Yet ‘ROWCS’ is a cognitive bias in itself and can lead to over-investigation, over-treatment and delayed decision making, referral or disposition in the wrong circumstance -- such as when condition Y is very rare or there will be time and opportunity for the patient to seek further assessment and treatment if her condition persists or worsens, making condition Y more likely. I suspect the answer is 42. ATB Chris